Written by Shahin Ghadir, MD (Southern California Reproductive Center)

What is Endometriosis?

The lining of the uterus is known as the endometrium. Endometriosis is a gynecologic condition in which bits of tissue similar to endometrium are found in areas of the body outside the uterus. Endometriosis lesions can appear anywhere in the pelvic cavity: on the ovaries, the fallopian tubes, the pelvic sidewall and the uterosacral ligaments. They can also appear outside the pelvic cavity – in the intestines, appendix, rectum, and even such far-flung places as the nose, although this is not common.

These lesions, termed “endometriosis implants,” respond to female hormones like estrogen and progesterone, just like the endometrial lining does. They can even bleed in microscopic amounts just like a menstrual period. This bleeding leads to local irritation and inflammation in the sites of implantation. The inflammation causes scar tissue to form, causing pelvic pain and impeding normal functioning of pelvic organs.

What is the Cause of Endometriosis?

The cause of endometriosis remains unknown, although a cornucopia of theories, ranging from bacterial infection to genetic abnormalities, has been proposed to explain this baffling disease. One theory suggests that endometrial cells, which are present in the menstrual flow, can back up into the fallopian tubes, implanting there and in the ovaries, then spreading through various routes, such as the lymphatic system, to implant in other parts of the body.

Endometriosis Symptoms

  • Pelvic pain
    The most common symptom of endometriosis is pelvic pain, often coinciding with the normal bleeding that occurs during the menstrual cycle – although pain may occur at any time. Pelvic pain results from the accumulation of scar tissue in the fallopian tubes, the most common implantation site. However, the ovaries, or any organ affected by endometriosis and the resultant scarring, can experience pain from inflammation and adhesions to other organs.
  • Cysts
    Endometriomas, also known as “chocolate cysts,” are pelvic masses that may develop in the ovaries. They are one of the most common endometriosis symptoms. The endometriotic tissue in a chocolate cyst undergoes its own “menstrual bleeding” during the menstrual cycle; the congealed blood trapped within the cyst resembles chocolate syrup.
  • Pain during intercourse
    Pain that occurs during intercourse, known as dyspareunia, is also one of the classic endometriosis symptoms.
  • Infertility
    Infertility is often the symptom that causes patients to seek endometriosis treatment.

What should I do if I have symptoms that point to endometriosis?

You need to be properly evaluated so you can get an accurate endometriosis diagnosis.

Call SCRC right away at (866) 312-0771 to speak to one of our caring fertility consultants, or click here to contact us. We will schedule a consultation for you with an SCRC fertility specialist at one of our offices who can help you.

Pregnancy and Endometriosis: Does it Cause Infertility?

There is a strong association between endometriosis and infertility, but a true cause-and-effect relationship has not been firmly established. However, we know infertility can result if:

  • Endometriosis lesions in the fallopian tubes cause scarring to the point of blockage, preventing sperm and egg interaction. In extreme cases, reproductive organs are fused together and do not function properly.
  • Ovarian cysts composed of endometriosis lesions (endometriomas, or “chocolate cysts”) impair egg production and ovulation.

In women with untreated endometriosis who are trying to conceive, the monthly fecundity rate (chance of pregnancy each month) is 2-10%, compared to 15-20% in the general population. Some studies have suggested that 30%-50% of women with endometriosis experience infertility.

Endometriosis Diagnosis

All of the symptoms described above may point towards an endometriosis diagnosis, but are not sufficient to establish a diagnosis. A pelvic exam can sometimes allow your gynecologist to identify endometriosis lesions by palpation (feel), but again, this is not reliable enough for a conclusive diagnosis of endometriosis. The only true way to diagnose the condition is through a minimally invasive exploratory surgery of the abdominal cavity called laparoscopy. Laparoscopy employs a lighted, fiber-optic tube (called a laparoscope) containing a camera and surgical instruments, which is introduced through a minimal incision in the abdomen. This gives the surgeon an excellent view of the pelvic and abdominal region. In this way, any endometriosis lesions can be easily identified and the endometriosis diagnosis confirmed.

Endometriosis Treatment Objectives and Approaches

In terms of treatment, it is important to clarify your goals. Some patients do not wish to conceive and just want relief from their pain.

For pain relief only (not infertility treatment):

A) Endometriosis Drug Treatment

  • NSAID Pain Relievers – Non-steroidal anti-inflammatory drugs like naproxen (Aleve) can often help in the management of endometriosis pain.
  • Hormones – By using hormones that stop menstruation and simulate pregnancy-like conditions, endometriosis lesions are deprived of stimulation. Without stimulation, the lesions atrophy instead of growing, leading to decreased inflammation and therefore pain relief. The following are effective hormone treatments for relieving endometriosis pain; however, they are not meant to be used in addressing infertility, because they either actually prevent pregnancy or do not help in conception.
  • Danazol – Danazol is a synthetic androgen, or male hormone, that stops women from menstruating and causes endometriotic tissue to atrophy.
  • Progesterone – Progesterone or a derivative such as medroxyprogesterone acetate (Provera or Depo-Provera) is a contraceptive. It works as an endometriosis treatment by creating a pseudo-pregnancy state.
  • GnRH Agonists – GnRH (gonadotropin-releasing hormone) agonists, such as Lupron (leuprolide acetate), work by suppressing estrogen production. When endometriosis lesions are starved of estrogen, they cannot grow or undergo menstrual bleeding, and they eventually atrophy. Lupron is a daily medication that patients inject themselves. Lupron Depot is a much more convenient formulation – a pellet your fertility doctor implants under the skin that delivers a measured dose of Lupron for three months. The convenience of this dosage form makes it an appealing option for endometriosis pain treatment.
  • Aromatase Inhibitors – A fairly new drug treatment proposed for endometriosis is a class of medicines called aromatase inhibitors. The two aromatase inhibitors on the market are letrozole (Femara) and anastrozole (Arimidex). They work by suppressing aromatase, an enzyme responsible for estrogen production. Aromatase inhibitors are more often used to treat gynecologic cancers, and are not currently FDA-approved as an endometriosis treatment.
  • You may have seen “natural” or “alternative” endometriosis treatments being promoted on the web or in other media. One such “natural” endometriosis treatment women have been hearing about is called Endovan; it claims to be an effective endometriosis treatment and is offered as an alternative to surgery and hormones. There’s even an endometriosis diet being touted as a cure for the disease. There is no clinical evidence whatsoever that any of these types of natural or alternative treatments can cure endometriosis or even relieve endometriosis symptoms.

B) Endometriosis Surgery

The most popular type of endometriosis surgery today involves using laparoscopy to remove endometriosis lesions from the pelvic region. The lesions are often “burned off” by a procedure called laser ablation. The laser apparatus is just one of the instruments passed through the laparoscope. The laser ablation referred to here should not be confused with the term “endometrial ablation.” Endometrial ablation refers not to ablation of endometriosis lesions, but rather to ablation of the endometrium (the actual lining of the uterus) itself. In addition to the destruction of pelvic endometriosis lesions, surgical removal of cysts and adhesions on the ovaries is also accomplished using laparoscopy. This type of endometriosis surgery offers better pain management over extended periods of time than drug treatment, but repeat surgery may be required in the future.

The endometriosis treatment that offers the best hope for a cure is a total hysterectomy – this is the removal of the uterus, both ovaries, and the fallopian tubes. This is a drastic treatment option, and should not be undertaken lightly, as pregnancy is no longer possible. Also, a cure cannot be completely guaranteed; rarely, endometriosis may return after hysterectomy.

Endometriosis Treatment to Address Infertility

For patients with endometriosis who wish to conceive, we will implement an aggressive treatment plan. Often patients with endometriosis need advanced treatments such as GnRH agonists (Lupron/Lupron Depot), and frequently, IVF (in vitro fertilization). In our experience as fertility specialists, we find that endometriosis presents a much greater infertility problem than the severity of the symptoms might suggest. Our patients with endometriosis who want to conceive tend to perform very well during the process of IVF; in fact, they do as well as patients that do not have endometriosis when undergoing IVF.

SCRC: Specialists in Endometriosis Treatment

If you have been previously diagnosed with endometriosis, or suspect that you have it (based on painful periods, pelvic pain or pain with sexual intercourse), you should call SCRC at (866) 312-0771, or click here to contact us and schedule a consultation for you with an SCRC fertility specialist. During your initial consultation, we will review endometriosis in depth with you and look for clinical clues to pinpoint your diagnosis.

After a comprehensive evaluation, our physicians will individualize a treatment plan for you. It may include surgical exploration of your reproductive organs using laparoscopy, or we may recommend proceeding directly with fertility treatments. We prefer to reserve surgical management for our younger patient population. We find that older patients tend to do much better by proceeding directly to IVF.

The fertility specialists at SCRC are experts in endometriosis treatment. Women have trusted us for nearly 30 years because of our specialized training, patience, and skill in dealing with this complex disease. Let us help you improve your quality of life while helping you conceive and build your family.

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